We carried out a review of the data available to us about Passion Healthcare Limited on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Passion Healthcare Limited, you can give feedback on this service.
Passion Healthcare Limited is a domiciliary care service providing personal care to people in their own homes. At the time of the inspection the registered manager confirmed the service was providing personal care to 55 people.
Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.
People’s experience of using this service and what we found
Staff were recruited safely. New staff were inducted, fully trained and competent in their role to meet people’s needs. Systems were in place to ensure staff practices were checked regularly. Staff received feedback on their performance through regular supervisions.
There were enough staff employed to meet people's needs. People were supported by regular reliable staff who they trusted. Rotas were planned to promote continuity of care and ensure staff worked within their contracted hours.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was requires improvement (published 3 October 2019).
Why we inspected
We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about staff recruitment, working hours and training. A decision was made for us to inspect and examine those risks.
Targeted inspections do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and effective sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Passion Healthcare Limited on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do we also consider any wider social care provided.
People’s experience of using this service and what we found
People felt safe with staff from the service. Care plans and risk assessments provided guidance for staff to follow. However, not all identified risks had been risk assessed to mitigate and reduce any identified risks. People felt safe with staff from the service. Staff understood how to protect people from the risk of harm and understood potential signs of abuse. People and relatives were involved in assessments of potential risks to safety and in identifying measures to keep them safe. Staff went through a recruitment process so that the provider only employed suitable staff.
People received their medicines as prescribed. They were protected from the risk of infections through staff working practices. People had enough staff to meet their needs. Staff undertook induction training that supported them to have the knowledge and skills to do their job well and effectively meet people’s needs.
People were provided with care and support that ensured they had good nutrition and hydration. They had access to healthcare that maintained their health and wellbeing. People were supported to have choice and control of their lives and staff supported them to do this.
Staff knew people well. People had developed positive relationships with staff which helped to ensure good communication and support. Staff respected people’s privacy and dignity and encouraged people to be as independent as possible.
People or their representatives were involved and consulted when making changes to how their support was provided. Staff knew and understood the needs of the people using the service and care was provided based on their assessed needs. Staff were responsive to changes in people's needs to ensure people received timely intervention to maintain their health and well-being.
People knew how to raise any concerns or make a complaint. The provider had a policy and procedure which involved investigation and solutions to put things right. This provided information about how these would be managed and responded to. This needed to include information about referral to another statutory body to approach if they were not satisfied with the investigation.
Systems were in place to monitor the quality of care and support people experienced through quality assurance systems and processes to drive improvements in the service, though a small number of issues have not been followed up.
People and staff spoke positively about the management and leadership of the service. People said staff were very friendly and caring, and they had good relationships with them. The service worked in partnership with external agencies to ensure people achieved good outcomes from their care and support.
Rating at last inspection:
The last inspection on 11 June 2018 rated the service as requires improvement.
Why we inspected
We carried out an unannounced comprehensive inspection of this service on 11 June 2019. Breaches of regulation 12, safe care and treatment and regulation 17, good governance were found. We issued requirement notices to the provider for these breaches. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.
We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements.
Follow up:
We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
The inspection took place on 11 and 12 June 2018. The inspection was announced because we wanted to make sure that the registered manager was available to conduct the inspection.
At our last comprehensive inspection in May 2016 we rated the service as 'Good'. On this inspection improvement was needed to ensure that people were comprehensively safe and that quality assurance systems had not been effective in driving improvements in the service. Because of these issues, the overall rating for this inspection has reduced to 'Requires Improvement.'
A registered manager was in post. This is a condition of the registration of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.
Risk assessments were not comprehensively in place to protect people from risks to their health and welfare.
Policies set out that when a safeguarding incident occurred management needed to take appropriate action by referring to the relevant safeguarding agency and to CQC. This had not been carried out for a potential suspicion of abuse.
Management had carried out audits in order to check that the service was meeting people's needs and to ensure people were provided with a quality service, though some issues had not been checked including issues which were identified on this inspection.
Staff recruitment checks were carried out to protect people from receiving personal care from unsuitable staff.
People and relatives told us they thought the service ensured safe personal care was provided by staff. Staff had been trained in safeguarding (protecting people from abuse) and understood their responsibilities in this area.
People told us that staff supported them with their medicines and records had shown this had happened.
Staff had received training on core important topics to ensure they had skills and knowledge to meet people's needs, though training on other relevant issues had not yet been provided.
Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choices about how they lived their lives. Staff were aware to ask people’s consent when they provided personal care. Mental capacity assessments were in place.
Most people and relatives told us that staff were friendly, kind, positive and caring. Not everybody told us they had been involved in making decisions about how and what personal care was needed their needs, though they did not feel this had any impact on the quality of care they received.
Care plans included important information on people’s needs, which helped to ensure that their needs were met, though there was not comprehensive information in place on people’s lifestyles and preferences.
People and their relatives were confident that any concerns they had would be properly followed up. Most were satisfied with how the service was run.
Staff members said they had been fully supported in their work by the management of the service.
We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.
We previously carried out an unannounced inspection of this service in November 2013. Breaches of regulations was found relating to a failure to fully promote people's welfare, checking that staff were fit to provide personal care to people and a lack of quality checking of services supplied to people.
After this inspection we asked the provider to produce an action plan stating what they would do to meet legal requirements in relation to the breaches. The provider sent this to us. This outlined action that would be put in place to ensure that these breaches in regulations were rectified. We found action had been taken to meet these breaches.
A registered manager was not in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The current manager stated that she would submit an application to be the registered manager of the service within a month of this inspection visit.
People and their relatives we spoke with said they thought the agency ensured that people received safe personal care. Staff had been trained in safeguarding (protecting people from abuse) and staff understood their responsibilities in this area.
Risk assessments were detailed to assist staff are to support people safely.
We saw that medicines were supplied safely and on time, to protect people’s health needs.
Staff had been safety recruited to ensure they were appropriate to supply personal care to people.
Staff had training to ensure they had the skills and knowledge to be able to meet people's needs, though more training was needed to ensure all people’s needs could be met.
Staff understood their responsibilities under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) to allow, as much as possible, people to have effective choice about how they lived their lives.
Staff had awareness of people's health care needs so they were in a position to refer to health care professionals if needed.
People and their relatives we spoke with told us that staff were friendly, kind, positive and caring.
People, or their relatives, were involved in making decisions about how personal care was to be provided.
Care plans were individual to the people using the service is to ensure that people's individual needs were met to ensure a fully personalised service was provided to them.
People or their relatives told us they would tell staff or management if they had any concerns and were mostly confident any issues would be properly followed up.
People and their relatives were satisfied with how the service was run by the management. There were comments for improvement from staff to ensure they were fully supported in their work.
Management carried out audits and checks to ensure the agency was running properly and ensure people were provided with a quality service.